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Oral Care Is Critical Care (Study Guide)

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  • 1. ICT continuing education Oral Care is Critical Care The Role of Oral Care in the Prevention of Hospital-Acquired Pneumonia By Suzanne Pear, PhD, RN, CIC Most critical care nurses, intensivists and included in VAP prevention success stories on its Bacteroides gingivalis mainly colonize the teeth healthcare epidemiologists have read the statistics Web site.5 The American Association of Critical while Streptococcus salivarius mainly colonize the about hospital-acquired pneumonia (HAP) and Care Nurses (AACN), recognizing the urgent need dorsal tongue. Another common commensal, ventilator-associated pneumonia (VAP). Pneumo- for clarification, issued a Practice Alert in August Streptococcus mitis, is found on both buccal and nia remains one of the most common causes of 2006 on the issue of “Oral Care in the Critically Ill.” tooth surfaces.8 These flora are usually considered death worldwide. HAP is one of the most common This document specifies the need to “develop and low-level pathogens which may take years or healthcare-associated (HAI) infections identified in implement a comprehensive oral care program for decades to produce clinically significant disease. U.S. hospitalized patients, with 90 percent of the patients in critical care and acute care settings who Role of Saliva 300,000 annual HAP cases occurring in ventilated are at high risk for healthcare-associated pneumo- Another important component of oral health patients (VAP).1 Nine to 27 percent of mechanically nia.”6 Such a program should include brushing is the continuous production of saliva, which ventilated patients develop VAP, and one episode teeth, gums and tongue at least twice a day with a is essential to keeping the mouth and its com- of VAP can increase the hospital length of stay by soft pediatric or adult toothbrush and moistening ponents clean and moist. Saliva is a mixed fluid an average of nine days and the cost of care by oral mucosa and lips every two to four hours. secreted predominantly from the parotid, sub- approximately $40,000.2 The AACN oral care guideline also recom- mandibular and sublingual glands. It provides Sixty percent of healthcare-associated infection mends using an oral chlorhexidine gluconate a number of important functions such as wash- (HAI) deaths are due to HAP/VAP. Most articles on (0.12 percent) rinse twice daily, but only on adult ing food debris and unattached microorganisms the subject of HAP/VAP usually begin by quoting cardiac surgery patients during their periop- from the mouth. In addition, saliva contains a similar facts and figures, in order to gain our atten- erative period.6 As part of VAP prevention, the number of immune substances such as immuno- tion and remind us how costly HAP/VAP is in terms Association for Professionals in Infection Control globulin A which obstructs microbial adherence of patient lives and healthcare dollars. This is good, and Epidemiology (APIC) exhorts clinicians to in the oral cavity and lactoferrin which inhibits as we need to be reminded and constantly vigilant make “patient oral hygiene standard practice” bacterial infection in the healthy individual.9 The in our HAP/VAP prevention efforts. for ventilated patients.7 dorsal surface of the tongue often traps residual Another positive impact is that organizations Aligning with the CDC, this clinical guidance debris not removed during swallowing and is like the Institute for Healthcare Improvement’s document describes oral hygiene as consisting known to harbor millions of organisms. Routine (IHI) “Lives Saved” campaigns’ VAP bundle3, the of “frequent tooth brushing, oral suctioning tongue cleaning is not generally performed by American Thoracic Society (ATS) pneumonia man- and swabbing of the mouth with antiseptic either patients or care providers.10 agement guidelines2 and the Centers for Disease agents.”7 According to this healthcare worker Oral Environment of Critically Ill Control and Prevention (CDC)’s HAI pneumonia (HCW) education publication, making routine The oral flora of critically ill adults differs prevention guideline,4 have provided programs oral hygiene a standard patient care intervention from that of healthy adults and contains organ- so that clinicians everywhere understand the has been found to reduce the incidence of VAP isms that can rapidly cause pneumonia. Within synergistic benefits of bundling evidence-based by 57.6 percent. 48 hours of admission, the composition of the practices to prevent HAP/VAP. oropharyngeal flora of critically ill patients under- We now know there is no single patient-care goes a change from the usual predominance of intervention that will eliminate HAP/VAP and that gram-positive streptococci and dental pathogens these bundles or guideline components need to to predominantly gram-negative organisms, con- be reliably performed for the full benefits to be stituting more virulent flora, including pathogens realized. Although not all of the evidence-based that can cause HAP/VAP within hours or days.11 HAP/VAP prevention guidelines recommend the Also, increased levels of proteases in the oral same strategies, one intervention that has been Figure 1. Sites of bacterial attachment in the mouth secretions of critically ill patients remove from recognized as a core or adjunct component of a their epithelial cell surfaces, a glycoprotein sub- pneumonia prevention program is comprehensive Why Comprehensive Oral Care stance called fibronectin. Normally, fibronectin oral care/oral-hygiene. The purpose of this article is Necessary to Prevent VAP is present on cell surfaces and acts as a host is to help connect the clinical dots between the Normal Oral Flora defense mechanism by blocking pathogenic reliable provision of comprehensive oral care and In order to appreciate why oral care is essential bacterial attachment to oral and tracheal mucus HAP/VAP prevention. for VAP prevention, it is necessary to understand membranes. This depletion of fibronectin in the the mouth of a healthy adult as well as the criticall ill allows cell receptor sites to replace What Is Comprehensive Oral Care? changes that occur in the mouth of the critically normal flora with virulent pathogens such as The CDC’s pneumonia guideline discusses the ill patient soon after admission into the health- Staphylococcus aureus and different strains of need to “develop and implement a comprehen- care setting. Most oral bacteria are considered gram negative bacteria, including Pseudomonas sive oral-hygiene program …for oropharyngeal to be part of the patient’s normal flora and may aeruginosa and Acinetobacter on buccal and cleaning and decontamination with an antisep- consist of up to 350 different species. Various pharyngeal epithelial cells.8 tic agent”4 but leaves the specific procedures to organisms tend to colonize different surfaces in If the critically ill or intubated patient does not clinicians. Although the IHI’s VAP bundle doesn’t the mouth. For example, Streptococcus mutans, receive effective, comprehensive oral hygiene, include oral care as a core measure, it is frequently Streptococcus sanguis, Actinomyces vicosus and then dental plaque and hardened bacterial depos-
  • 2. ICT continuing education its may develop on the teeth within 72 hours. identification of oral hygiene problems. This is followed by emerging gingivitis, gum Dental Plaque Removal inflammation, infection and a subsequent shift • Intervention: Use a small, soft toothbrush from primarily Streptococcus and Actinomyces to brush teeth, tongue and gums at least spp. to increasing numbers of aerobic gram-neg- twice daily to remove dental plaque. Foam ative bacilli.10 Since adhesion to a surface in the swabs or gauze should not be used, as mouth is important for the continued existence they are not effective tools for this task. and proliferation of organisms, bacteria which • Rationale: Dental plaque, identified as a attach to the tooth surface gradually coalesce to source of pathogenic bacteria associated produce a biofilm and after further development, with respiratory infection, requires lead to the formation of dental plaque.9 mechanical debridement from tooth, tongue and gingival surfaces. Xerostomia and Mucositis in the Toothpaste Critically Ill Patient • Intervention: Use toothpaste which Xerostomia is dry mouth and mucositis means contains additives that assist in the oral inflammation. Studies by Dennesen et al. breakdown of mucus and biofilm in the have documented a nearly absent salivary flow mouth. Figure 2. The Pathway to VAP in intubated sedated ICU patients which can be • Rationale: Additives such as sodium explained by several circumstances such as the tube hampers natural host protection and secre- bicarbonate have been shown to assist severity of the disease resulting in intubation and tion clearance mechanisms. It bypasses normal in removing debris accumulations on oral admission to the ICU, lack of normal oral intake, air filtration and physical capture of microorgan- tissues and teeth. fluid balance disturbances, extended use of mor- isms and particulates. The ET tube also blocks the Antiseptic Mouth Rinse phine required because of controlled mechanical mucociliary clearance mechanism as well as dis- • Intervention: Use an alcohol-free, antiseptic ventilation or pain management.12 ables the cough reflex and inhibits phagocytosis rinse to prevent bacterial colonization of Apart from the inadequate flow, the saliva is in the alveoli. Its very presence initiates “foreign the oropharyngeal tract. not distributed through the oral cavity in a supine body” reaction in the tracheal tissues, increasing • Rationale: Mouthwashes with alcohol cause sedated patient and severe xerostomia, severely secretory and inflammatory responses. excessive drying of oral tissues. Hydrogen reduced salivary flow and dry mouth, is therefore In addition, the ET tube acts as a direct peroxide and CHG-based rinses have been generally present in ICU patients. As the mucus conduit for pathogen access into the lungs, shown to assist in removing oral debris as membranes of the mouth dry out, the tissues allowing a biofilm or “slime layer” to form that well as provide antibacterial properties. become inflamed. A severe reduction of salivary allows microbes to multiply on its surface, which Moisturizer flow and subsequent xerostomia and mucositis can then dislodge and drop into the lungs. • Intervention: Use a water-soluble may result in increased oropharyngeal coloniza- Over pressure of the ET tube cuff can damage moisturizer to assist in the maintenance of tion with respiratory pathogens. As mucositis or (necrose) the tracheal wall, potentially caus- healthy lips and gums at least once every oral inflammation increases in the hospitalized ing long term damage as well as providing an two hours. and ventilated patient’s mouth, the level of oral inflamed site for bacteria migration and growth. • Rationale: Dryness and cracking of bacteria increases as well. The greater the level Contaminated secretions or dislodged biofilm oral tissues and lips provide regions for of oral bacteria, the greater the amount of bio- particles fall into the lungs directly through the bacterial proliferation. A water-soluble film that attaches to the patient’s teeth. Allowing ET tube or around the ET tube cuff. The lungs moisturizer allows tissue absorption and build-up of biofilm and resultant dental plaque, become contaminated with pathogenic micro- added hydration. if not removed, increases the bacterial load in organisms which may additionally proliferate Avoid Lemon Glycerin Swabs oropharyngeal secretions. Given the fact that all within the lung tissue. This cycle of contami- • Intervention: Avoid using lemon-glycerin patients aspirate secretions, even non-ventilated nation, aspiration and pathogen multiplication swabs for oral care to moisten oral mucosa. patients, the greater the amount and microbial continues. If these pathogenic microorganisms • Rationale: Lemon-glycerin compounds are contamination of aspirated secretions, the more overwhelm the body’s antibacterial defenses, acidic and cause drying of oral tissues. likely that lung infection, i.e., HAP/VAP will occur. the patient develops pneumonia. Assessment of Oral Cavity16 Therefore, a critical component of any evidence- • Intervention: Conduct an initial admission based HAP or VAP prevention bundle must be the The Recommended Interventions and as well as daily assessment of the lips, oral prevention of plaque formation by ensuring that Rationales of a Comprehensive Oral tissue, tongue, teeth, and saliva of each patients perform or receive thorough oral care, Care Protocol patient on a mechanical ventilator. especially mechanical debridement of biofilm Recommended oral care interventions for • Rationale: Assessment allows for initial and plaque at least twice daily.13 Comprehensive all hospitalized patients16 identification of oral hygiene problems and oral care interventions should focus on plaque Written Protocol and Training for continued observation of oral health. removal and stimulation of salivary flow.14 • Intervention: Written oral care protocol Elevate Head and training should be in place. • Intervention: Keep head of bed elevated The Pathway to VAP • Rationale: Policy is designed to provide at least 30 degrees, and position patient Why are ventilated patients more susceptible a standard of care which should be so that oral secretions pool into the to pneumonia? Two words – endotracheal (ET) reinforced in training and should allow for buccal pocket; especially important during tube. The ventilated patient’s normal defenses are consistent care of all patients. feeding, brushing teeth, etc. hampered, bypassed, blocked or disabled during Initial Assessment • Rationale: Elevation prevents reflux endotracheal tube-assisted mechanical ventilation • Intervention: Conduct an initial admission and aspiration of gastric contents; oral by the physical presence of the assistive-breath- assessment of the patient’s oral health and secretions may drain into the subglottic ing device as well as by medications used to keep self-care deficits. area where they can become rapidly these patients sedated.15 The presence of the ET • Rationale: Assessment allows for initial colonized with pathogenic bacteria.
  • 3. ICT continuing education Oral and Orotracheal Suctioning VAP.(24) Considering these data, it would seem What Are the Barriers to Reliable • Intervention: Suction patient’s that at best, CHG mouth rinse should be used as Comprehensive Oral Care in the ICU? mouth and oropharynx routinely and an adjunct to mechanical plaque removal with a Another large survey of ICU nurses investi- as indicated by patient’s secretion toothbrush, as opposed to replacing this essen- gated the factors affecting the quality of oral production, using either continous tial component of comprehensive oral care. care being provided in ICUs.(29) This study is subglottic suctioning or manual method. important because it identified, from the nurse’s Do not use same catheter to suction What is the Current Practice of Oral perpectives, what may be preventing them from both mouth and trachea. Care in the Adult ICU? providing optimal oral care. ICU nurses reported • Rationale: Minimize aspiration of A number of studies in the critical care literature still needing oral care education. They also said contaminated secretions into lungs. document the significant variability in the qual- that they have insufficient time to provide oral ity and quantity of oral care provided to patients. care, have trouble seeing oral care as a priority Does Reduction of Oral Microbial In 1999, a study investigated how oral care was and continue to view oral care as an unpleasant Colonization and Dental Plaque Really being performed in the adult ICU. The reseach- task. The reseachers concluded that improving Reduce VAP? ers identifed that nurses had not been formally oral care in ICUs is a multi-layered task – certainly The oral care intervention project reported by trained in assessing oral status of patients in ICUs not as simple as it appears on the surface. Their Garcia and colleagues helps connect the clinical and no formal protocol for mouth care existed. recommendations for improvement included the dots between dental plaque reduction and VAP Most nurses used a foam swab dipped in water need to reinforce proper oral care through edu- prevention.17 This study compared patients who or mouthwash to provide mouth care to patients, cation, de-sensitize nurses to the often-perceived received standard oral care (which consisted of but the method and frequency “varied from nurse unpleasantness of cleaning patients’ mouths and yankauer suctioning and glycerin swabs for mouth to nurse and patient to patient.”(25) As part of finally, the importance of monitoring compliance care) to patients who received comprehensive oral the study, the nurses then received training on oral while continuing to identify additional barriers to care. Comprehensive oral care included daily oral assessment plus implementation of a formal oral care as they emerge. assessment, teethbrushing, oral and orotracheal care protocol, which resulted in marked improve- suctioning, hydrogen peroxide rinse, oral mucosa ment in their patients’ oral health. Conclusion moisturizer, and use of a covered yankauer. The In 2004, researchers from the University of HAP and VAP continue to be the most lethal results of the study were that the group of ven- Louisville Schools of Nursing and Dentistry sur- and likely causes of death attributable to health- tilator patients who received the comprehensive veyed more than 550 nurses working in more care-associated infections. These infections are dental intervention had 42 percent fewer epi- than 100 ICUs about their oral care knowledge very costly in terms of lives lost and healthcare sodes of pneumonia. The researchers concluded and practices.(26) Ninety-two percent of the dollars wasted. National published guidelines for that careful oral assessment and improved oral nurses reported that they believed oral care to be HAP/VAP prevention, which rely upon published care reduces contaminated aspirates and results important, but only 20% used toothbrushes and research evidence, consider comprehensive oral in significant reduction in the incidence of sub- toothpaste when providing oral care. Almost half care to be essential care for prevention of pneu- sequent VAP. of those surveyed said they needed better oral monia in the hospitalized patient. The rapid, care supplies and wanted more evidence-based potentially pathologic changes in hospitalized Are Toothbrushes Better education about oral care. and ventilated patients’ oral environment make Than Foam Swabs for Plaque Removal? An interventional study which was reported in oral care a critical component of any HAP/VAP To answer this question, Pearson and 2005 monitored baseline oral care provided to 139 prevention bundle. Optimal oral care for pneu- Hutton conducted a time-series, cross-over mechanically ventilated patients at 5 different hos- monia prevention is not the comfort care that controlled trial with 34 volunteers which stud- pitals and 8 ICUs over a 2 month period.(27) The historically had been provided, e.g., oral suc- ied plaque accumulation and removal with observers noted that none of the ICUs had formal tioning with a yankauer and use of moistened the two oral care tools.18 The study found protocols and none of the patients had their mouths cotton or foam swabs. that toothbrushes performed substantially assessed, their teeth brushed, lips or mouths moist- Comprehensive oral care should focus better than foam swabs in removing plaque ened, oropharynx suctioned or suction tubing on plaque removal and stimulation of sali- from sheltered areas of teeth. The researchers changed. Nurses were still using either suction or vary flow. However, similar to hand hygiene, concluded that nurses should be educated on non-suction, moistened swabs to clean patients’ compliance with consistent provision of com- toothbrushing skills and need to be supported mouths. Two of the ICUs had suction toothbrushes prehensive oral care has not been as straight in developing oral care protocols, practice and available, but staff rarely used them. Additionally, forward as one would hope. The ability to assessment abilities. nurses reported providing oral care more frequently provide oral care in the ICU setting is ham- than was documented in the medical record. The pered by a number of factors including the Can Chlorhexidine Gluconate (CHG) intervention, which consisted of a multi-faceted competing priorities in a turbulent ICU for Mouth Rinse Take the Place of education program, including a standardized, com- nurses’ care and attention. It is essential that Toothbrushing? prehensive protocol and adequate oral care tools, all nurses receive evidence-based education A large number of studies have reviewed resulted in marked increase in the amount and fre- on the patient care practices which are neces- the effect of CHG mouth rinse on preven- quency of oral care provided. sary for improving patient outcomes. When tion of VAP, with conflicting results.(13,19-21) More recently, a study published in January nurses (and their hospital administrators) truly Two meta-analyses of these studies report that 2007 reported the findings from a survey of 1200 understand the criticality of providing compre- although CHG may reduce the incidence of VAP, nurses on their compliance with the CDC’s VAP hensive oral care to all patients, finding the it doesn’t reduce time on the ventilator or lower prevention guidelines.(28,4) Only 56% of the time to provide oral care will no longer be the mortality rate.(22,23) This confusing finding nurses reported having a formal oral care protocol, problematic. Patients will then receive com- may be the result of a number of factors, the 36% reported performing subglottic suctioning prehensive oral care as needed and HAP/VAP most relevant of which may be that CHG is not a and 34% routinely maintained patients’ head rates will approach zero tolerance. very effective antibacterial agent against gram- of bed elevated above 30o. Less than 40% of Comprehensive oral care really does negative or multiresistant bacteria, which are survey respondents reported knowing their unit’s make a difference! Oral care is critical care the pathogens most commonly associated with VAP rates or likely causative organisms. for all patients. ICT Reproduced with permission from Infection Control Today, October 2007 . For electronic usage only. Not to be printed in any format. ©2007 Virgo Publishing. All Rights Reserved.